Case Report the Rhinolith—A Possible Differential Diagnosis of a Unilateral Nasal Obstruction
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Hindawi Publishing Corporation Case Reports in Medicine Volume 2010, Article ID 845671, 4 pages doi:10.1155/2010/845671 Case Report The Rhinolith—A Possible Differential Diagnosis of a Unilateral Nasal Obstruction Detlef Brehmer1 and Randolf Riemann2 1 Private ENT Clinic Goettingen, Faculty of Medicine, University Witten/Herdecke, Friedrichstraße 3/4, 37073 Goettingen, Germany 2 Department of Otorhinolaryngology, City Hospital Frankfurt-Hoechst, Gotenstr., 6–8, 65929 Frankfurt, Germany Correspondence should be addressed to Detlef Brehmer, [email protected] Received 30 March 2010; Accepted 16 May 2010 Academic Editor: Gerd J. Ridder Copyright © 2010 D. Brehmer and R. Riemann. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rhinoliths are mineralised foreign bodies in the nasal cavity that are a chance finding at anterior rhinoscopy. Undiscovered, they grow appreciably in size and can cause a foul-smelling nasal discharge and breathing problems. Giant nasal stones are now a very rare occurrence, since improved diagnostic techniques, such as endoscopic/microscopic rhinoscopy, now make it possible to identify foreign bodies at an early stage of development. We report the case of a 37-year-old patient who, at the age of 5-6 years, introduced a foreign body, probably a stone, into his right nasal cavity. On presentation, he complained of difficulty in breathing through the right nostril that had persisted for the last 10 years. For the past four years a strong fetid smell from the nose had been apparent to those in his vicinity. Under general anaesthesia, the stone was removed in toto from the right nasal cavity. The possible genesis of the rhinolith is discussed, our case compared with those described in the literature, and possible differential diagnoses are considered. 1. Introduction may remain in the nasal cavity and grow in size through accretion of mineral salts and incrustation. As the rhinolith Today, rhinoliths are a rare occurrence. Rhinoliths are increases in size, the symptoms to which it gives rise may mineralised foreign bodies in the nasal cavity that are a range from unilateral nasal discharge, unilateral purulent chance finding at anterior rhinoscopy. The foreign body finds rhinitis with or without consecutive sinusitis, facial pain, its way into the nasal cavity almost always through the limen headache, epistaxis, impairment of nasal breathing ending nasi. According to Denker and Brunings¨ [1], such a situation in complete obstruction, dacryocystitis, otorrhea [4], foetor, was formerly most commonly observed in children and the anosmia, palatal perforation [3, 5], and septal perforation mentally retarded, who “for a lark,” as it were, inserted such [6]. The duration of the medical history may range from small objects as beads, small stones, coins, and suchlike into months to decades [7], and women appear to be more a nostril. Trauma, surgical operations and dental work, nasal commonly affected than men [8]. Although most rhinoliths packaging material, and plugs of ointment may also promote are detected in young adults, they may be found at any age the development of a rhinolith. In addition, vomit may enter (6 months to 86 years) [5, 9, 10]. The diagnosis is established the nose via the choana and remain there forming a foreign on the basis of the medical history and endoscopic findings; body. Finally, a rhinolith may develop spontaneously, for an imaging modality may provide additional information. example in the case of a long-standing chronic polypoid sinusitis with accumulation of secretions followed by mineral 2. Case Report deposition [2, 3]. Provided that the endonasal mucosa is intact, any tiny particles that may enter the nose during According to his own recollection, the 37-year-old patient inspiration are eliminated through the secretion of mucus had, at the age of 5 or 6 years, inserted a stone into his right and ciliary action. If the mucosa is damaged, such particles nasal cavity. Over the course of time, this event had been 2 Case Reports in Medicine 7 R Figure 1: Rhinolith in the right nasal cavity. Figure 2: Coronal CT showing a calcified space-consuming lesion occupying much of the right nasal cavity. completely forgotten. He now presented, with right nasal obstruction accompanied by a purulent discharge from the right nostril and a foul smell from the nose, of which he himself was unaware. After clearing the nasal cavity of the secretion by aspiration, and detumescence of the mucosa, a blackish solid foreign body was detected at the level of the piriform aperture, which almost completely occluded the right nasal cavity (Figure 1). The axial/coronal CT scan of the nasal cavity, obtained to exclude bony destruction, revealed a large, dense, space-consuming lesion measuring between one and a maximum of three cm in diameter located in the inferior and middle meatus on the right, and presenting partly regular, partly irregular margins and caused shadowing of the right maxillary sinus (Figures 2 and 3). No bony destruction was evident. Under general R anaesthesia, the rhinolith was broken into two fragments and ERIOR removed (Figure 4). In addition, the right maxillary sinus was cleared out via an infraturbinal window. After 32 years Figure 3: Axial CT scan showing the rhinolith in the right nasal in situ, the foreign body had displaced the intact septum to cavity, with consecutive shadowing of the right maxillary sinus. the left. The inferior and middle turbinates were atrophic. Histological examination of the biopsy material excised from the mucosa of the nasal cavity and septal mucosa revealed remaining 10% being made up of organic substances incor- chronic, florid, ulcerous, nonspecific, in part hyperplastic, porated into the lesion from nasal secretions. Mineralogical and polypoid inflammation. After applying the usual post- investigations employing powder diffractometry unequiv- operative care, the patient became symptom-free, and an ocally identified the mineral whitlockite (Ca3 (PO4)2)as endoscopic inspection of the maxillary sinus performed on representing the main constituent of a rhinolith. In addition, the 5th postoperative day revealed healed, bland endothelial the mineral apatite (Ca5 (OH, F, CI) (PO4)3)andcarbon- mucosa. ated apatite (dahlite) have also been identified. Another author describes an extremely rare iron-containing rhinolith, the X-ray diffraction analysis of which revealed siderite 3. Discussion 2+ (Fe CO3 and ferrihydrite (5Fe2O3 × 9H2O) [18]. This The first published report of a calcified foreign body in author suspected an exogenous iron-containing nidus to the nose appeared in 1654, in which Bartholini described be the likely cause, since the endogenous development of a stone-hard foreign body that had grown around a cherry an iron-rich rhinolith is not conceivable; the physiological stone [11]. The term rhinolith was first coined in 1845 to secretions (nasal mucus, tears) produced in the nose contain describe a partially or completely encrusted foreign body in no demonstrable amounts of iron. the nose [11]. Calcified incrustations in the nasal cavity were The calcified foreign bodies in the nose were formerly subjected to a chemical analysis, first by Axmann in 1829 designated false or true rhinoliths. Today, these terms have [12], and thereafter by various other authors [2, 11, 13–17]. been replaced by exogenous and endogenous, depending on In general they comprise 90% inorganic material, with the whether or not a nucleus, around which the incrustation has Case Reports in Medicine 3 married. Some 8 years later, her persistent breathing problem prompted her to make a further attempt to have it surgically treated. Once again the rhinolith remained undetected and no operation was performed. At the age of 71, the patient consulted an ENT specialist for a hearing problem, and, at last, the rhinolith was discovered incidentally and removed. The stone had thus remained in situ for 61 years. This case described by Bader and Hiliopoulos [22], with all its human tragedy, illustrates the fact that despite typical symptoms, the diagnosis of a rhinolith is not always easy—as Seifert noted in 1921 [23]—and this underscores the need for an endoscopic examination of the nasal cavities [24]. Figure 4: Removed rhinolith. In most of the cases, the rhinolith is located in the inferior nasal meatus [11]. The literature also contains an occasional absolute rarity, such as a living foreign body, for example, been deposited, can be found. Those rhinoliths that have a living leech [25]. However, the literature also contains developed around nonhuman material introduced into the reports of rhinoliths that were only identified because of the nose and remaining in situ such as cherry stones, stones, severe complications they caused, such as perforation of the forgotten nasal swabs, or similar objects are termed exoge- hard palate bony destruction, and expansion of the stone nous. Endogenous rhinoliths are those that have developed into the maxillary sinus, facial tetanus, or septal perforation around the body’s own material such as, for example, ectopic [5, 6, 9, 11, 26]. teeth in the maxillary sinus, bone sequesters, dried blood In the case described herein, a pronounced, nonper- clots in the nasal cavity, and inspissated mucus [19, 20]. forated displacement of the septum to the left, together Some 20% of the rhinoliths are of endogenous